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Who Will Do Abortions Here?

On a cold Minnesota morn- ing, the abortion doctor and I pushed his six-seater plane out of the hangar and onto the runway. We removed the leather nose cozy (handmade by his wife), cranked the prop and minutes later were aloft above the linear plats etched along the Laurentian Divide. We were heading east to Fargo, where the doctor single-handedly keeps North Dakota's last abortion clinic open every Wednesday.

Alexander Nicholas is part of a growing trend among abortion providers. (Nicholas is not his real name; he's hiding his identity because, he said simply, ''my life is in jeopardy now.'') At one point last year, he was touching down in Minnesota, North Dakota, Wisconsin and Indiana. In the trade, these new frequent-flier docs are called ''circuit riders.'' He is proof of two things: that the medical infrastructure undergirding the right to an abortion is strained to the breaking point and that the practical reality of abortion is retreating into a half-lighted ghetto of pseudonyms, suspicion and fear.

''I really don't see a solution to this problem,'' Nicholas said, ''until medicine is presented with a crisis.'' He may not have long to wait.

Twenty-five years ago this week, the Supreme Court legalized abortion with its decision on Roe v. Wade, and since then, the legal and moral contests surrounding Roe have achieved a kind of odd stability. The most conservative Supreme Court in half a century has embraced the principles of the 1973 landmark decision. And the moral debate plays out like an unending episode of ''Crossfire,'' almost reassuring in the way anti-abortion and abortion-rights positions rerun on a continuous tape loop.

In recent years, the number of women terminating a pregnancy has also remained fairly constant, about 1.5 million a year. The doctors who serve the system are another matter. Today, 59 percent of all abortion doctors are at least 65 years old. That's not a typo: nearly two-thirds are beyond legal retirement age. Most doctors who perform abortions specialize in obstetrics and gynecology; according to a study done three years ago, the percentage of OB-GYN's willing to perform abortions dropped from 42 percent in 1983 to 33 percent in 1995. (Doctors going into what's called family-practice medicine were thought by some to be part of the next generation of abortion providers, but a study published in October revealed that only 15 percent of chief residents doing family practice had any experience with the simplest abortion procedure.)

OB-GYN's learn the surgeries and procedures associated with abortion during their hospital residency programs. A 1991 study showed that only 12 percent of these programs now routinely teach abortion, and, according to Philip Darney, a professor at the University of California at San Francisco's medical school, all indications are that the percentage is ''still trending down.''

One factor in this is the growth in hospital mergers.-- Many bring together institutions with no religious affiliation and Catholic hospital chains like the Sisters of the Sorrowful Mother. The Catholic Church is, of course, firmly against abortion, and typically, one immediate result of this sort of merger is the elimination of abortion training and birth-control counseling.

Few medical schools dare to even mention, much less teach, the mere facts of abortion. My wife finished medical school last year. She never heard the word ''abortion'' mentioned in a classroom. Which medical school was it that neglects to expose students to what is one of the most common surgeries among American women? Yale.

''I am training a young woman right now in Duluth,'' Nicholas explained as the plane zipped across a landscape of infinite fleece. ''She's doing it as part of a family-practice residency at the clinic, but she had to request it and is training on her own time.'' He spoke in a measured way, like nearly everybody in the Coen brothers' movie ''Fargo,'' and his blue eyes were friendly beneath his winter muscrat hat.

''It's very different for people like her,'' he added. ''A lot of doctors don't want partners who perform the service.'' This is one of the reasons nearly 9 out of 10 abortions are done not in doctors' offices or in hospitals but in clinics like those Nicholas regularly visits. This phenemenon has played a concrete role in moving abortion off the main street of prestigious American medicine toward the half-hidden back alley from where it once emerged.

Nicholas knew that old world. In the hospitals of Chicago, where he was a resident in the 1960's, survivors of botched abortions regularly limped in or were carried in to receive his care. ''They were bleeding, had foreign bodies in their vagina or came in with temperatures of 106,'' he said.

''The younger doctors especially don't have the history we have with the procedure,'' he said. ''They don't know how women were affected in the old days. They're out of the loop because they never had to go through what we did. They have no experience.''

If the right to an abortion seems here to stay, the medical system that has provided the safe, legal abortions can no longer be taken for granted. The medical schools and hospital residency programs that have stopped teaching abortion are responding, in part, to the argument that abortion is immoral. But mostly they are responding to the same fears that keep providers like Nicholas from allowing their real names to be used. This fear pervades every aspect of abortion, and has driven it increasingly into a kind of medical netherworld, where doctors wear bulletproof vests and students learn what they can where they can and research is relatively rare. This shadow world, in turn, makes the providing of abortions less and less appealing even to those doctors who consider themselves ''pro-choice.''

The murders in 1993-94 of five abortion doctors and clinic staff members who were gunned down has changed every aspect of the abortion debate. Operation Rescue, which claimed no responsibility, nonetheless collapsed. Its 50 state chapters now number 8. But by wrecking itself on its own increasingly violent rhetoric, the anti-abortion movement has won an important battle. It made the abortion procedure a dangerous, undesirable and even somewhat illegitimate thing to do: among doctors.

Once upon a time, Nicholas was greeted with gratitude by women. Now he is often met on the tarmac by gangs of mostly men screaming curses at him. He has received phone calls in which cold voices ask menacingly, ''How's your plane flying, Alex?'' Just three weeks before I arrived, an abortion doctor just over the border in Canada was shot through the window of his house while he ate dinner. A photograph of Nicholas's plane circulates among anti-abortion Internet sites.

The overwhelming majority of abortions are performed by a small group of doctors. (Some 2 percent of OB-GYN's perform more than 25 per month.) ''Most doctors love it that someone else is performing the service,'' he said, ''because they don't have to worry about the hate mail and the harassment. But I'm not going to keep doing this until I have one foot in the grave.'' Nicholas, one of the younger pups in this field, is 60. He said he plans to be hunting moose full time when he's 62.

''I'm not going to do this forever.''

LOST HISTORY, OR WHAT A YOUNG DOCTOR DOESN'T KNOW

In any society, the terms of a particular debate have a way of shaping the outcome, and this is very much the case with abortion. In a sense, abortion medicine is being undermined rhetorically as much as any other way. These days it has become impossible to talk or think about abortion in any terms others than those of moral revulsion. It's either pure evil (the ''pro-life'' view) or a necessary evil (the ''pro-choice'' view). Even feminists have, in recent years, engaged in a discussion to redefine abortion in terms of transgression and mourning.

But in the plane with Nicholas, and later in other interviews with doctors whose early careers predated Roe, I discovered a theme I hadn't anticipated. None of them could speak about abortion as a moral issue because their initial encounter with abortion was not as an argument, but as an emergency.

Their histories date back to women who had back-alley abortions that resulted in internal infections and other, more disturbing complications. Legalization has largely eliminated this, as well as the estimated 5,000 abortion-related deaths that occurred annually in the years before Roe. The dichotomy for these doctors is not legal or illegal, moral or immoral, but safe versus unsafe.

''It's one thing to remove the uterus of a woman who had had children,'' said David Bingham, a 57-year-old OB-GYN who has been doing abortions since his residency in the years just prior to Roe. ''What was really hard was to remove the uterus of some 16-year-old because of gas gangrene, and to know that she would never have a family.''

The belief that abortion is a form of preventive medicine is prevalent among older doctors. As such, many of the sentiments I heard from them are all but unvoiced today, opinions out of some 1973 time capsule.

''I save lives,'' he repeated, his tone desperate. ''I respect these people who have picketed outside my office for 25 years, in and out of snowstorms. Obviously they believe in what they are doing and are very persistent. At the same time, I have taken care of many of their wives and children and even some of the people on the picket line who suddenly find themselves in a way different situation than they ever thought possible. I know what would happen if they were successful politically -- a lot more tragedy, a lot more deaths. I saw what it was like when it was illegal. Look -- we have saved tens of thousands of lives, maybe hundreds of thousands.''

I heard this again from Richard Hausknecht, a 68-year-old Park Avenue OB-GYN who helped open the first New York clinic in 1970 at 73d and Madison. ''You are preserving a woman's life,'' he said, ''by not forcing her to take the extreme measure of a life-threatening illegal abortion or having a child when it's totally inappropriate to do so.''

This kind of talk about abortion, unheard on the political talk shows and the floor of Congress, is, strangely, just as rare among those studying to become doctors who perform abortions. I interviewed a number of OB-GYN residents in the fall, and among the questions I asked was why had they learned the procedure. They answered that ''I am pro-choice'' and it's ''a matter of privacy'' and ''women's rights,'' but never ''I save lives.'' Hausknecht, who also teaches at Mount Sinai Medical School, detected a similar change during a recent lecture he gave to students on abortion history.

''I showed them slides of death rates due to abortion prior to Roe,'' he said. ''It didn't have any impact. It was as if I were talking about tuberculosis'' -- by which he meant something that was eradicated years ago.

The passage of Roe v. Wade did not erase a medical history in which ''abortionist'' was an insult worse than ''quack.'' Abortion is the only procedure singled out by Hippocrates for inclusion in the oath, which strictly forbids it (and which is why modern doctors recite an edited version of Hippocrates's original words).

The history of abortion isn't widely known for the simple reason that almost none of abortion's past serves either side of the contemporary debate very well. For example, abortion was legal in America from 1607 to 1828. The drive to outlaw it in the 19th century had little to do with morality. Doctors were beginning to professionalize, so they pushed for a ban on abortions as a remedy for the bad medicine they saw being practiced by profiteering charlatans and well-intentioned midwives.

Unfortunately, their successful effort to make abortion illegal simply drove it into the back alley, where, according to some estimates, as many as two million abortions a year were performed -- a number that if even half accurate should sober up today's Victorian nostalgists. The movement to legalize abortion in the 1970's was motivated by the same medical logic that had led to its ban: to eliminate botched abortions. To that extent, Roe has been successful. Deaths at the hands of self-taught abortionists virtually disappeared after 1973. And other statistics began to change. Bingham, who served as a case reviewer in Detroit for the Centers for Disease Control in the early 70's, said the impact of the first states to legalize abortion was immediate.

''The day abortion became legal in New York state,'' he recalled, ''was also the day that we -- in Detroit -- noticed that the number of patients coming into the hospital with 'miscarriages' plummeted.''

Because residents have no knowledge of abortion history before Roe, they see their choice to perform abortions as a political one. And they are often disturbed to discover that the women they serve, more often than not young or poor or both, don't speak the language of constitutional rights.

''For some it is definitely a kind of birth control,'' said one weary OB-GYN resident I spoke with in a hospital not far from Manhattan. She believes in abortion rights and does abortions, but like all such residents I interviewed, she spoke only on the condition of anonymity, fearing harassment or worse by abortion foes. ''These women are on their sixth one. They have a troubled family situation, and you feel it's in the best interest for the possible future child.'' Her voice grew slow and sad. ''In some ways I do feel that -- but it doesn't make it any more pleasant.''

The chief resident at the same hospital said: ''Some days you just want to shake these people. 'Why didn't you take your birth-control pills? Why didn't you get your Depo-Provera shot?' ''

These OB-GYN residents seemed to get little satisfaction, as doctors, in doing abortions -- the satisfaction, however sober, that they saved a life by carrying out the procedure in a medical setting. For any doctor, there is pride in performing a technique well and seeing a patient on the mend -- that's what the doctors who remember the horrors of the back alley say they feel. This is lost on the residents I spoke with. Some of them have the kind of revulsion you expect to find among abortion protesters.

''If you do 12 in a row, it can make you feel bad,'' the chief resident said. ''No matter how pro-choice you are, it makes you feel low.'' Another resident said: ''I guess I never realized I would find it as unpleasant as I do. I really don't enjoy it all. It's not a rewarding thing to do.''

She went on to say that, truth be told, she preferred doing second-trimester abortions -- a more difficult surgery -- to the simple first-trimester abortions.

''Why?'' I asked.

''Because the patient is asleep,'' she said. Many of the women who come in are often drug addicts, with nervous systems so frayed they have exceptionally low pain thresholds. ''They look at you as an evil person who is deliberately putting them through a painful procedure. I just feel like explaining to them that this is not something that I am going out of my way to do. It's their whole attitude that bothers me. I feel like a simple thank-you is in order instead of 'Why are you doing this to me?' ''

Among OB-GYN residents willing to perform abortions, there is also, oddly enough, disparaging talk about those doctors who perform many abortions, particularly those, like Nicholas, who travel from clinic to clinic, working long hours at great risk. One resident referred to the clinics as ''factories.'' Another who worked there said, ''That whole world is a mystery to me.'' Finally, one OB-GYN who supports abortion rights but has chosen not to perform abortions said bluntly what the others were probably thinking: ''It's seen as the dirty work of our field. The sad truth is that the people who moonlight at the clinics are grade-B doctors. They're not the cream of the crop. And it's not because they're committed. It's because they can't find steady work.''

When I raised this with Dr. Hausknecht, he grew annoyed, but acknowledged that the prejudice is very much alive in medicine. ''It's true that abortion providers are perceived as not very good doctors -- that they have no alternative so they do abortions, that they cannot earn a living any other way,'' he said. The fear of getting too much of an abortion reputation preys on the minds of residents and influences their career decisions.

''I was thinking of doing a study last year,'' one resident said. ''I wanted to look at different gestational ages and then compare them to outcomes among different types of abortion. But then I started to think, Well, gosh, wait a minute, I don't want to end up being known as the abortion person, do you know I mean?''

THE ABORTION ELECTIVE, OR WHAT A DOCTOR IS NOT REQUIRED TO LEARN

''My wife,'' said William Rashbaum, a OB-GYN in a large East Coast city, ''told me I owe it to women before I die to make sure others have my skills.'' But training is slow. He said that he can't devote as much time as he would like to since, at age 71, he still shuttles full time between his private office and several hospitals to help with current demand.

While few OB-GYN residency programs routinely teach abortion procedures, many do allow residents to learn it as an outside elective -- at, for example, Planned Parenthood, which arranges for residents in programs that don't teach abortion to rotate through a clinic nearby. But for residents who typically work between 80 and 100 hours a week, the offer of taking an elective course in their ''spare time'' constitutes a cruel joke.

In every program that teaches abortion, anyone can opt out on moral grounds, and many do. Those who want to learn the procedure know they are, in a sense, being penalized -- working even longer hours, often feeling a bit cheated. ''Residents who do abortions know they are being pulled from learning other procedures,'' said the chief resident I interviewed, ''because they are the only ones doing abortions. What else are they missing? I know that among some residents there is a little bit of resentment.''

From day one, said one resident, the issue of just who will and will not perform abortions is a topic that just hangs in the air. Eventually folks ''just kinda know,'' he said, who will be doing the procedure. ''And it's hard not to suspect that some people opt out because they are looking for any way to lighten the load.'' In his program -- ensconced in a liberal Northeastern teaching hospital -- only half the OB-GYN resident are learning the technique.

''Abortion is the only procedure you can choose not to learn,'' another resident said. ''I can't say 'I don't believe in hysterectomy' or 'I don't believe in tubal ligation' and therefore won't learn the procedure. Abortion's the only one you can opt out of learning for whatever reason. It can be real or unreal. You just might want to get out of work. It sounds cynical, but in a residency? Absolutely.''

Few residents would have encountered abortion in medical school. Efforts to remedy the curricular absence of abortion training have been led by the American Medical Women's Association. The organization has developed a full course on birth control, including abortion, and has been pressing the medical schools to add it to the curriculum. But the going is slow. Of the 160 medical schools in America, only 5 offer the course, and in each case it is an elective.

To combat the sense of isolation among the students who want to learn how to perform abortions, a group was founded three years ago called Medical Students for Choice. One of the group's members described how she was scolded by an OB-GYN professor for mentioning abortion in a casual conversation on the wards. When she lobbied to start up a chapter at her medical school, faculty pressure was applied to change the name to Students for Reproductive Health and Freedom -- anything to avoid that protest-inducing word ''choice.''

In 1995, the Accreditation Council for Graduate Medical Education decided to get tough and announced that all OB-GYN residency programs would be mandated to provide abortion training (although individual residents could still opt out for moral reasons). This was met in Congress by the Dan Coats Amendment, which insured that any residency programs unaccredited because of abortion training would continue to receive the Federal financing that underwrites all accredited residency programs. In the end, the ''mandate'' became a ''recommendation'' to provide ''elective'' training. No school has been unaccredited.

A LACK OF RESEARCH AND INNOVATION, OR WHAT NO ONE KNOWS ABOUT THE 'PARTIAL-BIRTH' PROCEDURE

The one area of abortion medicine that appears to be thriving is research. From time to time the news media relate some new procedure that holds out the promise of removing abortion from doctors and the clinic, and thus, the thinking goes, from the anti-abortion movement. You might get the impression that research laboratories remain unaffected by the strains felt by other aspects of abortion medicine. But evidence of abortion's marginality can be found even here.

Take, for instance, the new form of first-trimester abortion that uses the drug methotrexate. Like the procedure utilizing the better known drug RU-486, the methotrexate abortion requires an initial visit to a doctor for a shot of the drug; the patient then follows up by taking four pills of a different drug at home.

The man who pioneered this technique and who achieved the rare distinction of publishing a full study in The New England Journal of Medicine under a solo byline was Dr. Hausknecht. During a grand rounds lecture at Mount Sinai one morning in the fall, he was lauded by his peers as a ''pioneer'' and a ''hero.''

Then, during the question-and-answer period, one doctor put it bluntly: ''Is this the panacea long sought by certain feminist groups so that women can bypass the physician?''

Hausknecht shook his head no. All methotrexate abortions had to be supervised by a doctor and the patient had to have ready access to an abortion facility. In the event of complications, an old-fashioned surgical abortion must be performed. And because methotrexate can involve several visits and side-effects -- vomiting, bleeding, nausea -- the procedure introduces a new problem to the issue: an ongoing awareness of the abortion process. Not many women, Hausknecht believes, would choose methotrexate over the immediate physical and psychological resolution of the surgical method.

In an interview with Hausknecht in his office, I discovered that the rare occurrence of having only his name on the article was not, it turned out, a badge of honor. Actually, it simply meant that his own department at Mount Sinai -- once headed by the famous reproductive-health pioneer Alan Guttmacher -- wouldn't put up its money or prestige for the study.

''I had to charge my patients,'' Hausknecht said. ''The research was self-funded. It's difficult to write good scientific research by your lonesome. It would be nice to have a biostatitician to help you. Nice to have colleagues tear it apart and put in their 2 or 20 cents' worth.'' The reason Hausknecht is a ''pioneer'' has as much to do with simply pursuing abortion research as it does with his results.

''You can look at any medical meeting of any kind in recent history,'' said Dr. Jane Hodgson, an abortion pioneer who will turn 83 the day after Roe's anniversary later this week. ''You will not find a single paper given on abortion.''

Consider the effort American researchers contribute to any other field or tool in reproductive health: in vitro fertilization, ultrasound, superovulation, adoption, birth control -- American know-how is deeply involved in all innovations. But abortion? When Americans have been involved, abortion's ambiguous history is never far off. The soft tube, or cannula, used to penetrate the uterus was developed by Harvey Karman, hence the ''Karman cannula'' still found in any medical catalogue. Karman was not a doctor, but he performed abortions pre-1973, if you get my drift.

Almost all developments in abortion medicine have happened elsewhere. The suction-curettage procedure dates to work done years ago in Communist Hungary. Prior to some abortions, the cervix must be dilated, typically by inserting sticks fashioned of twisted seaweed, which when wet expand -- a process perfected centuries ago by the Japanese. The use of prostaglandins, the compounds used to terminate second-trimester pregnancies, originated in Sweden.

RU-486 -- which operates a lot like methotrexate -- is French. It was once predicted to be widely available in the United States by mid-1997, but it remains all but impossible to get. It is being tested in secret locations and manufactured by a secret company; the plan was to have it eventually shipped by a secret middleman. However, one result of this furtive distribution apparatus, created to avoid anti-abortion ''action alerts,'' is that the pill's American patent-holder, the Population Council, managed to unknowingly hire a disbarred lawyer (he was convicted of forgery) to serve as the business manager. So the entire RU-486 procedure is currently tied up in the courts.

''RU-486 is no closer today to being available than it ever was,'' Hausknecht said.

New abortion procedure or techniques tends to emerge slowly, and from a kind of half-light -- a fact overlooked during last year's battle over third-trimester abortion. Interestingly, the furor concerned terminology, with abortion-rights activists maintaining that conservatives' use of ''partial birth'' was a loaded description, and one never used by doctors. The proper medical term, they said, is ''intact dilation and extraction,'' or ''D and X.'' But most OB-GYN's I spoke with had never heard that term before the controversy. Few knew how, or where they could learn, to do one.

So I called a few doctors who performed these procedures. One said he taught it, and not long after, I found myself in the deepest shadows of abortion medicine, dressed in one of those blue paper surgical outfits with shoe coverings and tissuey snood -- smuggled into an operating room. I was watching a resident watching a doctor in order to learn the procedure.

The patient lay on her back on the operating table, her ankles dangled in the air, gently held by a loop of cloth tied to high steel poles. At the tap of a button, the bed rose, bringing her womb up to working level, and the doctor lowered a clear plastic face mask, like an arc welder's. The doctor inserted his gloved right hand deeply into the patient's vagina until only his thumb protruded.

''I am looking for a foot,'' he said to the resident standing beside him. I stood directly behind them. He pulled out a foot, a bit longer than an inch.

''There is the foot,'' he said. ''Now you pull the one leg and then you reach in and flex the other one like this.'' He re-inserted a single forefinger into the vagina and suddenly two legs, froglike, appeared. The skin was translucent, membranous. The feet quickly turned a dark purple. Within minutes, so did the legs. The doctor gripped each leg as if holding hedge clippers.

''Place each thumb on the buttocks,'' he instructed. The pads of his thumbs and the fetus's buttocks were perfect matches in size and shape. ''Then turn and twist like this.'' He pulled firmly. A back appeared, then with the flick of a forefinger, a small arm fell out and then another. The anesthesia had relaxed the natural paisley curl of the fetus into something linear and flaccid. A 10-inch homunculus, its head locked into the cervix, hung in full view, motionlessly toward the floor, its long tapered legs disturbingly elegant.

It happened quickly. The back of the fetus's skull was punctured. There was a tiny spurt of blood into the stainless-steel waste can that sat on the floor beneath. A curette was inserted, a hose was attached and the deep rumble of the suction machinery near me kicked on. Into a clear plastic jar at my feet there appeared instantaneously about a half-inch of pinkish fluid marked by tiny whitish-gray globules. On some animal level, deep in my own brain stem, I knew what it was and leapt back in fear. The periphery of my vision went gray, and a minute later, when my equilibrium returned, I found myself standing amid an ancient medical ritual.

The doctor was excoriating the resident for giving too many wrong answers to hard questions he had posed during the procedure. This particularly humiliating variation of the Socratic method is a form of hazing that medical students call ''pimping.''

''What are the three most important words in medicine?'' the doctor yelled.

The resident was speechless. The doctor seized the student's cheeks with both hands and pulled his face as close as a boot-camp sargeant's.

''What are they?'' the doctor roared.

''I don't know,'' the resident said meekly, his chin digging into his chest in abject humility. The doctor smiled the smile of a man who had set this verbal trap a hundred times before.

''Precisely,'' he said. ''I . . .Don't. . .Know. Learn to say them.'' After the resident left, I asked the doctor what else the young doctor would have to do to learn about a D and X. He looked at me oddly. Else? There was nothing else.

Most surgical procedures are taught via hands-on experience, but young surgeons are also required to take classes, read books, attend meetings of their peers and keep up with the improvements found in the periodical literature. But none of this support exists for the D and X. In fact, it's not just the phrase ''partial-birth abortion'' that can't be found in the medical books, neither can ''intact dilatation and extraction.''

Why? Because much of the ''continuing education'' in abortion technique occurs in quickly arranged opportunities, on the fly, by word of mouth.

''When you get caught in the middle of an abortion that is further along than anticipated,'' Bingham said, ''you have a tremendous motivation to find out what to do. So that's when we would just discuss with each other what worked to get out of that situation.''

The channels of communication among abortion doctors more closely resemble the oral tradition from the pre-electronic bush. The doctors dwell in relative isolation in their offices or clinics. There is not a lot of chance for conventioneering. The local manager of the Holiday Inn isn't really eager to arrange the plastic letters on the roadside sign to read, ''Welcome abortion providers!'' So they talk among themselves. The third-trimester abortion controversy broke out only after the very first draft paper describing the procedure was leaked in 1993 to the National Right to Life Committee.

Even though there are OB-GYN periodicals willing to disseminate information about new techniques, getting information out is not the problem.

''It's not that they won't publish research,'' Hausknecht said. ''It's that they have no research to publish.'' And what little there is arrives at a sluggish pace. ''We would have had RU-486 and methotrexate 15 years ago if weren't for the politics,'' Dr. Bingham said.

The Internet is a help. Probably more professionals have learned about methotrexate from a Web site devoted to Hausknecht's work (www.medicalabortion.com) than from the original New England Journal of Medicine article. But the normal organizational conduits of medicine just aren't operative for abortion. I asked Hausknecht when the last time was that the A.M.A. had anything to say about abortion. ''They came out in favor of the partial-birth ban,'' he replied darkly. ''That's about it.''

The job of clearing information and maintaining standards -- something the A.M.A. traditionally does for medicine has fallen to abortion's own private organization, the National Abortion Federation. The N.A.F. is a Washington-based association of abortion providers, but it does much more than any other typical guild of like-minded professionals. As if to underscore just how remote abortion is from mainstream, prestigious medicine, the N.A.F. is perhaps best understood as a kind of mini-A.M.A. Abortion is the only field in medicine to have one, or need one.

LIVING A LIFE IN THE SHADOWS, OR HOW ABORTION SHAPES ONE HEARTLAND LIFE AND MAY SOMEDAY AFFECT A LOT OF OTHERS

Dr. Alexander Nicholas is a devoutly Catholic father of three, which is not everybody's idea of an abortion provider. I first met him at his home, a modest one-story house of aluminum siding and brick on an average American street. He invited me there because he wanted me to see that it ''was no Cadillac deal.''

His wife, Amelia, dressed in slacks and a sweatshirt boasting the name of her curling club, invited me to the breakfast table for a snack. Her silver napkin ring had a black plastic tag glued to it that read ''Grandma.'' The kitchen was overrun with evidence of Christmas chores. Two tins' worth of bonbons cooled nearby. I was invited to sample her most prized confection, a blend of green and pink miniature marshmallows, Rice Krispies and peanuts held together by almond bark.

''They got more 'bark' than bite, don't they?'' the doctor commented as we munched.

Not knowing what else to do, I just ground the gears and rudely shifted the conversation from marshmallows to abortion -- more specifically, to how he and his wife go about their lives in the abortion netherworld. Their cheery Midwestern can-do-ism never faltered.

''Oh, it hasn't been so bad,'' Amelia said. ''Except 1993, when members of Operation Rescue surrounded the house day and night for a week of candlelight vigils. That was no good.''

''Some good came of it,'' Dr. Nicholas leapt in. ''That couple down the street -- we'd never really done anything with them. Son of a gun, he brings us a pie.''

The town also held a rally, arguing that Nicholas's right to a regular life in his home with his family was as important as the moral debate about abortion. Nicholas's insistence at finding the good in what's happened is not just a product of his Midwesternness. It's now a part of his mental survival. Most of his days are filled with a constant low-grade foreboding.

After Nicholas landed the plane in Fargo, we were met by one of the clinic staff members. We drove through town and pulled up to the clinic, a small blue-trimmed house next to the Holiday gas station. A man and a woman in thick parkas paced back and forth across the driveway. The man was holding a sign that read ''Never to Laugh,'' leaving a new visitor uncertain about whether the sentiment applied to him.

''Oh, gosh,'' Nicholas groaned, ''I see we got Timmy and Cathy today,'' referring to the protesters. The staff member pulled the car around back behind a high fence. She looked at me and mouthed the words ''Bring yourself to Christ.'' As I got out of the car, the exact same words came droning over the fence, like a rote response in a litany: ''Bring yourself to Christ.''

The woman driving rolled her eyes at me again and then in a singsong voice said, ''Alex, you were born a Catholic.''

Immediately, like the refrain from a dirge, ''Alex, you were born a Catholic'' floated over the top of the fence.

The entire moment was comical and creepy, reminding me of nothing more than that Warner Brothers cartoon of the sheep dog and wolf who punch a clock every morning just outside the herd of sheep. Morning, Ralph. More, Sam. Then they spend the day merrily going through the same circular motions -- comical because at their core they are potentially violent.

Legalized abortion has become the most hashed over political and theological debate in a nation devoted to debates. The pro and con exchanges are as rehearsed as ''The McLaughlin Group.'' The national animosities break out continuously, along old lines, so frequently that they repeat in almost mythic cycles.

Today, we watch as RU-486 sets off protests, but most of us have forgotten that the reason no company would openly manufacture the drug is that corporate executives remember the protests staged against Upjohn in the 1970's when that company agreed to produce prostaglandins. Likewise, the national disgust at the harrowing third-trimester-abortion procedure is very similar to the horror following the arrest and conviction of Dr. Kenneth Edelin in 1975 for manslaughter. His crime was performing a rare procedure called a hysterodomy. His conviction was eventually overturned. Dr. Bingham explained that the procedure entails ''delivering the fetus by C-section -- it was moving but was unable to breathe at this point and it was allowed to expire.''

According to the polls, public opinion ebbs and flows like a tide between revulsion at the procedures of abortion and insistence on a woman's right to one. We are nothing if not conflicted. In a 1990 Catholic Conference poll -- typical of dozens of polls -- 60 percent of Americans believed that every ''unborn child'' has a right to life. At the same time, 69 percent believed that basic abortion should be legal.

The same polls that show Americans deeply conflicted also show that when the national conversation is focused on the fetus, the squishy middle tends to express more anti-abortion sentiments. But when the debate turns to women being harassed and deprived of the fundamental American right to make up one's own mind, the pendulum lumbers over to the other side. Political tacticians know this and try to engineer media controversies to work one way or the other at election time. That is why Jesse Helms stood in the well of the Senate and detailed over and over the visceral mechanics of a third-trimester abortion.

The procedure is profoundly upsetting. The image of that limp suspended fetus has not left me. By the time I traveled back home -- two days later -- I had trouble holding my 8-month-old daughter. That fetus appeared in my dreams, but then so did another arresting picture that surfaced, unbidden, from my mind's archives. It was the cover, I believe, of a Village Voice in the early 1980's. In black-and-white, it showed the hall of a hotel where illegal abortions were performed. On the floor lay a white woman, unnaturally pale -- and naked. What made it especially scary to look at was that the normal length and elegance of her adult body were curled into a fetal ball, as if she were cold. But she, and her fetus, were dead.

The older doctors believe that a safe abortion has two benefits beyond eliminating such horrors. It gives poor women the same access as middle-class women (who always had it, long before Roe, and always will, regardless of what new restrictions are passed by any Congress). And, because the existence of a safe, available procedure reduces the suffocating sense of desperation an unexpectedly pregnant woman feels, legalization actually results in fewer abortions.

There is good evidence to support this latter view. Chile, for example, has an absolute-no-exception ban on abortion, and the penalty can be stiff: up to 5 years in prison for the mother. Chile also has one of the highest per capita abortion rates in Latin America. Ireland, the only Western European country except Malta to prohibit access, is thought to have an abortion rate higher than the Netherlands, where laws governing access have long been liberal.

This distinction between poor and well-off patients seeking abortions is another issue that tendsto only be discussed among providers. ''The problem in training doctors to perform abortions,'' Dr. Rashbaum said, ''is that the commitment to performing them has as much to do with the poor as with women.'' He described a certain doctor he had recently trained and then said: ''He's a good doc, but he'll never stick with it. He doesn't have the commitment to the poor. I just don't see a lot of that these days.''

To serve poorer women was why abortion clinics were developed in the first place, right after Roe became law. Hospitals charged up to $1,000 back then, which was too much for many women, particularly those still in school or in the inner cities. One consequence of the rise of these clinics (where abortions still cost only a few hundred dollars) was that, even before the anti-abortion movement gained momentum, the abortion procedure began to slip away from prestigious medical institutions into free-standing clinics. Today, for example, 7 percent of abortions are performed in hospitals, 4 percent in doctors' offices. The rest are performed in clinics.

''The institutions lost control, and interest,'' Hausknecht said. ''Academic physicians of major institutions had started doing abortions after Roe because they were the ones with access to new techniques. But if you look at them today, academic physicians are the most uninvolved group.''

Now the clinics -- cut off from medicine's protection, prestige and research -- have become part of abortion's problem. It's easy for doctors to think of the procedure as something outside medicine because the surgery is literally not happening around them. Many of these clinics are also being segregated into poor neighborhoods because terrified landlords in middle-class areas won't rent to them or because they need a cheap rent to compensate for increased security costs. In many ways, the clinics are returning to the back alley.

The vision of a new procedure or cutting-edge technology alleviating the problem is a chimera. What kind of patient will opt to have Hausknecht's methotrexate, RU-486 or the new technique out of Houston that allows for an abortion within 10 days of conception?

''They will be popular with educated women who have definite opinions about what they are doing,'' Rashbaum said. Few poorer women, he added, will be among the first to embrace these new, more private, more high-tech procedures. ''The poor don't think about medical care until they are very uncomfortable,'' he said. ''And pregnancy isn't that uncomfortable.'' The poor and the uneducated, his experience leads him to conclude, are the most likely to procrastinate, forcing themselves to consider abortion later, when finding a doctor willing to perform a second-trimester is most difficult.

As more and more middle-class women avoid the agony of the clinics by choosing the privacy of pills, that would leave abortion clinics and abortion politics to our system's most politically enfeebled constituency -- single, largely minority women. It is a bleak scenario, one in which abortions and the doctors who provide them would be pushed even further into the shadows.

The passage of Roe v. Wade was a signal event for OB-GYN's practicing in 1973. But the watershed moment for a new generation of doctors was the spree of fatal shootings that began in 1993. Praise for saving women from illegal abortionists has been replaced by fear of helping another person exercise a constitutional right. Medicine has yielded to politics.

Rights are meant to be exercised in a clear light, in all towns and neighborhoods and cities, without fear of ostracism or physical harm. Abortion-rights advocates say abortion should be the exception. The medical establishment has backed away from such vehemence, leaving the practical day-to-day work of abortion overwhelmingly to the same doctors who first pioneered it 25 years ago. Now they are growing old, and soon they will die, and there is the prospect of their not being replaced.

Should this happen, Americans would face a once-obsolete political conundrum, one we haven't really thought about since the founding fathers tried to dispatch it into history. We're a little rusty at considering questions like this: Can people be said to possess a right if they're too afraid to exercise it?